222 Shallowbrook Dr Lot 25-26 a, - -..... ...n, n. .:..\ .k:., ♦i'a'..:�.:-:t,. ♦l c - c. ai aaa .i 5 t -. - ff ..... ,. _., . • ._
DAVIE .COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
•"NQS E: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name _— 1 ; ! Date
Location
Subdivision Name Lot No. ��! ' l Sec. or Block No.
Lot Size House /- Mobile Home _ Business Speculation
No. Bedrooms No. Baths ' '' No. in Family 11Z _
Garbage Disposal YES [] NO ❑ Specifications for System:
Auto Dish Washer YES 0 NO
Auto Wash Machine YES `i' NO
�i✓ tJf�'�/ /F..�I:' � =t l Cts _ ( L G'+•.`t�...�r7,/....� i
Type Water Supply __—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.sue.
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Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: Systaninstalled by
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Certificate of Completion /.;G.
%� -�� Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
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-APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department 1
r Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By aohn uon[e 7r Business Phone 74 7- /s4<o
2. Address S;b)a-T nib/Qa F- 4 w-S - Z7 I o 3
3. Property Owner if Different than Above C1o�(' &0e Sm i rn'Z de
Address
4. Permit To: a) Install EfL"Alter Repair
b) Privy Conventional zOther Type
Ground Absorption
c) Sub-Division V-1" Sec. Lot No.&-JZ� �4 4-o lev k
5. System used to serve what type facility: House-----Mobile Home Business
IndustryOther
b) Number of people 7
6. a) If house or mobile home, state size of home and number of rooms.
House DimensionssQad a 5G
Bed Rooms Bath Rooms c2 y2- Den w/Closet�—
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes ✓ urinals garbage disposal
lavatory '' showers washing machine
dishwasher ✓ sinks ✓
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes ✓No
9. a) Property Dimensions S ez )n�
b) Land area designated to building site
c) Sewage Disposal Contractor -
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is rect to t best of my knowledge.
Date Owner nature
OWNER IS SOLELY RESPONSIBLE FOR CO PLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-62)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• ' R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��� Date Zz—&2hZ
Address Lot Size cl iy5e-17)6
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U ` U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by _ `��" Title Date
SITE DIAGRAM
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DCHD(6.82)